Anorexia nervosa: What you need to know
The condition commonly involves emotional challenges, an unrealistic body image, and an exaggerated fear of becoming overweight or obese.
It often begins during the teenage years or early adulthood, but it can begin in the preteen years. It is the third most common chronic illness among teens.
Eating disorders affect some 30 million men and women in the United States. Both men and women can develop anorexia, but it is 10 times more common in females. Nearly 1 in every 100 American women will experience anorexia at some time.
Anorexia nervosa is different from anorexia, which means a loss of appetite or inability to eat.
Here are some key points about anorexia nervosa. More detail is in the main article.
- Anorexia nervosa is a psychological condition that involves an eating disorder.
- Symptoms include a very low body mass index (BMI), a refusal to eat, and attempts to lose weight, even when body mass index is very low.
- It is thought to be triggered by a combination of biological, environmental, and genetic factors.
- Treatment can take some time, but with a combination of counseling and other types of therapy, recovery is possible.
What is anorexia nervosa?
Anorexia can lead to a distorted body image and an unwillingness to eat.
Anorexia nervosa is a psychological condition and an eating disorder in which the individual loses more weight than is healthy for their height and age. The individual will maintain a body weight of 85 percent or less of their expected weight.
A person with anorexia will intentionally restrict their food intake, generally due to a fear of being or becoming fat, even when their body mass index (BMI) is already low. They may also practice excessive exercise, use laxatives, and vomit to reduce weight, but to a lesser extent than those diagnosed with bulimia.
Complications can be severe. Eating disorders are reported to have the highest mortality rate of any mental illness.
Treatment includes hospitalization and counseling.
Anorexia nervosa is a complex condition, but the main sign is usually severe weight loss. The person may also talk about being overweight, although objective measures, such as BMI, show that this is not true.
Behavioral changes may include a refusal to eat, exercising excessively, and use of laxatives or vomiting after consuming food.
Other physical signs and symptoms resulting from a lack of nutrients include:
- severe loss of muscle mass
- listlessness, fatigue, exhaustion
- hypotension, or blood pressure
- lightheadedness or dizziness
- hypothermia, or low body temperature, and cold hands and feet
- bloated or upset stomach and constipation
- dry skin
- swollen hands and feet
- alopecia, or hair loss
- loss of menstruation or less frequent periods
- osteoporosis, or loss of bone density
- brittle nails
- irregular or abnormal heart rhythms
- lanugo, fine downy hair growing all over the body, and increased facial hair
Signs of vomiting include bad breath and tooth decay, due to the acid in the vomit.
Psychological signs and symptoms include:
- excessive concern about being fat or overweight
- frequently measuring and weighing themselves and inspecting their bodies in the mirror
- obsession with food, for example, reading cookery books
- lying about food intake
- not eating or refusing to eat
- lack of emotion or a depressed mood
- reduced sex drive
- memory loss
- obsessive-compulsive behavior
Food and eating become associated with guilt. It may be difficult to talk to the person about a possible problem, as they will likely refuse to acknowledge that anything is wrong.
Media pressure and fear of gaining weight are sometimes, but not always, contributing factors.
No single cause has been identified for anorexia nervosa. It probably happens as a result of biological, environmental, and psychological factors.
The following risk factors have been associated with it:
- being susceptible to depression and anxiety
- having difficulty handling stress
- being excessively worried, afraid, or doubtful about the future
- being perfectionist and overly concerned about rules
- having a negative self image
- having eating problems during early childhood or infancy
- having had an anxiety disorder during childhood
- holding specific ideas regarding beauty and health, which may be influenced by culture or society
- having a high level of emotional restraint or control over their own behavior and expression
The person may be overly worried about their weight and shape, but this is not necessarily the key factor.
Between 33 and 50 percent of people with anorexia also have a mood disorder, such as depression, and around half have an anxiety disorder, such as obsessive-compulsive disorder (OCD) and social phobia. This suggests that negative emotions and a low self image may contribute, in some cases.
A person may develop anorexia nervosa as a way of gaining control of some aspect of their life. As they exert control of their food intake, this feels like success, and so the behavior continues.
The fashion industry and media messages suggesting that being thin is beautiful may have an impact.
Other environmental factors may include:
- physical, sexual, emotional or another types of abuse
- family or other relationship problems
- being bullied
- a fear or exams and pressure to succeed
- a stressful life event, such as bereavement or becoming unemployed
According to the United Kingdom's (U.K.'s) Counseling Directory, people with anorexia "genuinely need to be in control of their lives; they need to feel special, and they need a sense of mastery."
Research published in the American Family Physician describes a person with anorexia as using "caloric intake or excessive exercise to control emotional need or pain."
When a person feels out of control of one or more aspects of their life, not eating may be one way in which they can at least take control of their body.
Biological and genetic factors
Studies have found that some people with eating disorders may have an imbalance in certain brain chemicals that control digestion, appetite, and hunger. Further research is needed to confirm this.
Genetic factors may affect a person's susceptibility to eating disorders, as they can run in families. Between 50 and 80 percent of the risk for anorexia is thought to be genetic.
A vicious cycle
Once a person starts losing weight, a low weight and lack of nutrients may contribute to brain changes in a way that reinforces the behaviors and obsessive thoughts related to anorexia nervosa.
The changes could involve the part of the brain that controls appetite, or they could increase the feelings of anxiety and guilt that become associated with eating.
In 2015, researchers found that people with anorexia nervosa may have different gut microbial communities than those without the condition. The authors suggested that this could contribute to anxiety, depression, and further weight loss.
A 2014 study found that people with anorexia nervosa are less able to differentiate between different types of positive emotion. This can lead to further weight-loss behavior, as self-deprivation becomes associated with a sense of pride.
An early diagnosis and prompt treatment increase the chance of a good outcome. A full medical history can help with diagnosis.
The physician will ask the patient about weight loss, how they feel about their weight, and, for females, about menstruation. It can be hard for the patient to open up and speak frankly about themselves. It can take years to confirm a diagnosis, especially if the person was previously obese.
If the physician detects signs of anorexia nervosa, they may order tests to rule out other underlying medical conditions with similar signs and symptoms.
- Addison's disease
- chronic infections
- inflammatory bowel disease (IBS)
These may include blood tests, imaging scans, and an electrocardiogram (ECG).
According to the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), the diagnostic criteria for anorexia nervosa are as follows:
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
The National Eating Disorders Association (NEDA) note that even without meeting all these criteria, a person may have a serious eating disorder.
Treatment and recovery
Anorexia nervosa is not only about avoiding food, but it brings emotional challenges, too.
Treatment can involve medication, psychotherapy, family therapy, and nutrition counseling.
It can be difficult for a person to accept that they have anorexia, and it can be hard to engage them in treatment, as the resistance to eating is hard to break.
The patient may fluctuate in their level of cooperation and acknowledgment that there is a problem.
A comprehensive plan must be tailored to meet the individual's needs.
The goals of treatment are:
- To restore body weight to a healthy level
- To treat emotional problems, including low self-esteem
- To address distorted thinking
- To help the patient develop behavioral changes that will persist in the long term
Treatment tends to be long-term, and relapse is possible, especially during times of stress. Support from family and friends is crucial to successful and lasting outcomes. If family members can understand the condition and identify its signs and symptoms, they can support their loved one through the process of recovery and help prevent a relapse.
Counseling includes cognitive behavioral therapy (CBT), which focuses on changing the way the person thinks and behaves. CBT can help a patient to change the way they think about food and body weight, and to develop effective ways of responding to stressful or difficult situations.
Nutrition counseling aims to help the patient regain healthful eating habits. They learn about the role of a balanced diet in maintaining good health.
There is no specific medication, but nutritional supplements may be needed, and the doctor may prescribe drugs to control anxiety, obsessive-compulsive disorder (OCD), or depression.
Research has indicated that the antipsychotic drug, olanzapine, may help patients reach a higher body weight, after which they can use an SSRI.
Hospitalization may be needed if there is severe weight-loss or malnutrition, a persistent refusal to eat, or a psychiatric emergency.
The intake of food will be increased gradually to enable safe weight gain.
Complications can affect every body system, and they can be severe.
Physical complications include:
Cardiovascular problems: These include low heart rate, low blood pressure, and damage to the heart muscle.
Blood problems: There is a higher risk of developing leukopenia, or low white blood cell count, and anemia, a low red blood cell count.
Gastrointestinal problems: Movement in the intestines slows significantly when a person is severely underweight and eating too little, but this resolves when the diet improves.
Kidney problems: Dehydration can lead to highly concentrated urine and more urine production. The kidneys usually recover as weight levels improve.
Hormonal problems: Lower levels of growth hormones may lead to delayed growth during adolescence. Normal growth resumes with a healthful diet.
Bone fractures: Patients whose bones have not fully grown yet have a significantly higher risk of developing osteopenia, or reduced bone tissue, and osteoporosis, or loss of bone mass.
Early diagnosis and treatment reduce the risk of complications.
Living with anorexia nervosa
Medical News Today (MNT) asked Maria Rago, Ph.D., the President of the National Association of Anorexia Nervosa and Associated Disorders (ANAD) what individuals, friends, and family can do if they think they or a loved one may have anorexia nervosa.
She gave us these tips:
- Be kind and respectful rather than judgmental.
- Look into providers of treatment to find good matches, and meet with some of the people to decide who can best help.
- Consider a treatment team including a dietitian, a therapist and a psychiatrist all who specialize in eating disorders.
- Make sure that you get all of the education and support that you can.
- Review your treatment and make changes when you think best.
"Remember that people get better every day. Remember that recovery takes time, so be patient with yourself and your loved one. Have hope, be creative and never give up. Be the captain of your recovery team. Try to understand the difference between your own voice and the voice of your eating disorder."
Maria Rago, President of ANAD
Ms. Rago noted that ANAD has free support groups and mentoring programs for recovery, and they invite people to take advantage of the free services. "The right help can change your life, and even save your life," she said.